Ultrasound‐guided arterial cannulation in the paediatric population

Christian K Raphael; Nour A El Hage Chehade; Joanne Khabsa; Elie A Akl; Marie Aouad-Maroun; Roland Kaddoum

doi:10.1002/14651858.CD011364.pub3

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 1: First‐attempt success rate

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Analysis 1.2

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 2: First‐attempt success rate (per artery site)

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Analysis 1.3

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 3: First‐attempt success rate (per age group)

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Analysis 1.4

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 4: First‐attempt success rate (per experience with ultrasound)

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Analysis 1.5

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 5: Incidence of complications (haematoma)

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Analysis 1.6

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 6: Successful cannulation within first two attempts

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Analysis 1.7

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 7: Overall successful cannulation after multiple attempts

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Analysis 1.8

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 8: Number of attempts to successful cannulation

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Analysis 1.9

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 9: Duration of cannulation procedure (seconds)

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Analysis 1.10

Comparison 1: Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler), Outcome 10: Duration of the cannulation procedure (seconds) – sensitivity analysis

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Summary of findings 1. Summary of findings table

Outcomes	Anticipated absolute effects (95% CI)		Relative effect (95% CI)	No. of participants (studies)	Certainty
Ultrasound‐guided arterial cannulation compared with palpation or Doppler guidance for children and adolescents
Patient or population: children and adolescents Setting: various surgical procedures in operating rooms/ICU/emergency departments in university hospital settings in Germany, Japan, Lebanon, Singapore, Thailand, Canada and USA Intervention: US‐guided arterial cannulation Comparison: other techniques (palpation/Doppler)
Outcomes	Risk with other techniques (palpation/Doppler)	Risk with US‐guided arterial cannulation	Relative effect (95% CI)	No. of participants (studies)	Certainty
First‐attempt success rate	Study population		RR 2.01 (1.64 to 2.46)	708 (8 RCTs)	⊕⊕⊕⊝ Moderate^a
First‐attempt success rate	242 per 1000	487 per 1000 (397 to 596)	RR 2.01 (1.64 to 2.46)	708 (8 RCTs)	⊕⊕⊕⊝ Moderate^a
Incidence of complications (haematoma)	Study population		RR 0.26 (0.14 to 0.47)	420 (5 RCTs)	⊕⊕⊕⊝ Moderate^a
Incidence of complications (haematoma)	218 per 1000	57 per 1000 (31 to 102)	RR 0.26 (0.14 to 0.47)	420 (5 RCTs)	⊕⊕⊕⊝ Moderate^a
Successful cannulation within first 2 attempts	Study population		RR 1.78 (1.25 to 2.51)	134 (2 RCTs)	⊕⊕⊕⊝ Moderate^a
Successful cannulation within first 2 attempts	358 per 1000	638 per 1000 (448 to 899)	RR 1.78 (1.25 to 2.51)	134 (2 RCTs)	⊕⊕⊕⊝ Moderate^a
Overall successful cannulation after multiple attempts	Study population		RR 1.32 (1.10 to 1.59)	374 (6 RCTs)	⊕⊕⊕⊝ Moderate^b
Overall successful cannulation after multiple attempts	606 per 1000	800 per 1000 (667 to 964)	RR 1.32 (1.10 to 1.59)	374 (6 RCTs)	⊕⊕⊕⊝ Moderate^b
Number of attempts to successful cannulation	Study population		—	368 (5 RCTs)	⊕⊕⊕⊝ Moderate^a
Number of attempts to successful cannulation	The mean number of attempts to successful cannulation was 2.12 attempts	MD 0.99 attempts fewer (1.15 fewer to 0.83 fewer)	—	368 (5 RCTs)	⊕⊕⊕⊝ Moderate^a
Duration of cannulation procedure	Study population		—	402 (5 RCTs)	⊕⊕⊕⊝ Moderate^c
Duration of cannulation procedure	The mean time to successful cannulation was 331.3 seconds	MD 98.77 seconds shorter (150.02 shorter to 47.52 shorter	—	402 (5 RCTs)	⊕⊕⊕⊝ Moderate^c
CI: confidence interval; ICU: intensive care unit; RCT: randomised controlled trial; RR: risk ratio; US: ultrasound.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^a Downgraded one level owing to risk of bias concerns (selection bias and performance bias). ^b Downgraded one level owing to a moderate level of heterogeneity (I² = 54%) and risk of bias concerns (selection bias and performance bias). ^c Downgraded one level owing to potential bias in two studies that set a 10‐minute time limit.

Summary of findings 1. Summary of findings table

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Comparison 1. Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 First‐attempt success rate Show forest plot	8	708	Risk Ratio (M‐H, Random, 95% CI)	2.01 [1.64, 2.46]

1.2 First‐attempt success rate (per artery site) Show forest plot	8	708	Risk Ratio (M‐H, Random, 95% CI)	2.01 [1.64, 2.46]

1.2.1 Radial artery	6	562	Risk Ratio (M‐H, Random, 95% CI)	1.98 [1.57, 2.48]
1.2.2 Femoral artery	2	146	Risk Ratio (M‐H, Random, 95% CI)	2.16 [1.37, 3.42]
1.3 First‐attempt success rate (per age group) Show forest plot	8	708	Risk Ratio (M‐H, Random, 95% CI)	2.01 [1.64, 2.46]

1.3.1 Children aged over four years	1	152	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.46, 2.24]
1.3.2 Neonates and children aged up to four years	7	556	Risk Ratio (M‐H, Random, 95% CI)	2.11 [1.71, 2.60]
1.4 First‐attempt success rate (per experience with ultrasound) Show forest plot	8	708	Risk Ratio (M‐H, Random, 95% CI)	1.98 [1.61, 2.42]

1.4.1 Little experience with US	3	362	Risk Ratio (M‐H, Random, 95% CI)	1.66 [1.11, 2.46]
1.4.2 More experience with US	5	346	Risk Ratio (M‐H, Random, 95% CI)	2.11 [1.66, 2.67]
1.5 Incidence of complications (haematoma) Show forest plot	5	420	Risk Ratio (M‐H, Random, 95% CI)	0.26 [0.14, 0.47]

1.6 Successful cannulation within first two attempts Show forest plot	2	134	Risk Ratio (M‐H, Fixed, 95% CI)	1.78 [1.25, 2.51]

1.7 Overall successful cannulation after multiple attempts Show forest plot	6	374	Risk Ratio (M‐H, Random, 95% CI)	1.32 [1.10, 1.59]

1.8 Number of attempts to successful cannulation Show forest plot	5	368	Mean Difference (IV, Random, 95% CI)	‐0.99 [‐1.15, ‐0.83]

1.9 Duration of cannulation procedure (seconds) Show forest plot	5	402	Mean Difference (IV, Random, 95% CI)	‐98.77 [‐150.02, ‐47.52]

1.10 Duration of the cannulation procedure (seconds) – sensitivity analysis Show forest plot	4	328	Mean Difference (IV, Random, 95% CI)	‐99.99 [‐160.30, ‐39.68]

Comparison 1. Ultrasound (US)‐guided arterial cannulation versus other techniques (palpation/Doppler)

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